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Overall health insurance rates changed little among nonelderly black, Latino
and white Americans between 2001 and 2003, according to new findings from the
Center for Studying Health System Change (HSC). But sources of coverage shiftedespecially
for Latinosfrom employment-based insurance to public coverage, suggesting the
economic downturn took a greater toll on Latinos. Low-income Latinos and whites
were particularly hard hit by declines in employer coverage. Shifting sources
of coverage had little effect on access to medical care. With the sole exception
of decreased access to specialists among blacks, access to care did not change
between 2001 and 2003. Significant gaps in access to care among Latinos, blacks
and whites persisted, with Latinos and blacks consistently reporting lower levels
of access than whites.

Shifting Insurance Coverage

he ongoing gap in the proportion of uninsured Latino, black
and white Americans essentially remained unchanged between 2001 and 2003, with
one in three Latinos, one in five blacks and one in 10 whites under age 65 lacking
health insurance in 2003 (see Table 1). While overall
coverage rates remained fairly constant, coverage sources shiftedparticularly
for Latinos, who saw a marked decline in employer-sponsored coverage and a commensurate
increase in public coverage.

All Americans saw a drop in access to employer-sponsored health insurance
between 2001 and 2003, but the decline was especially severe for Latinos. Less
than 65 percent of nonelderly Latinos had access to health insurance from employers
in 2003, compared with more than 71 percent in 2001 (see Table
2). Moreover, the proportion of eligible Latinos who took up an offer of
employer coverage dropped from 79.5 percent in 2001 to 72.3 percent in 2003.
In comparison, more than 80 percent of whites and blacks had access to employer
coverage in 2003, while 92.2 percent of whites and 83.6 percent of blacks took
up offers of employer-sponsored insurancerates that have remained virtually
unchanged since 1997.

2 Other coverage includes private nongroup insurance, private insurance
obtained from someone outside the family, Indian Health Service and other
miscellaneous coverage. Military insurance and Medicare for disabled persons
are excluded from this analysis.

1 A working family is defined as one in which total number of hours worked by all adult members
of the family is 20 or more hours per week. Dependents of adults on active military duty
are included while families in which all adult members are self-employed and have no paid
employees are excluded.

2 Access rate is defined at the family level. As long as one member of the family has access to
employer coverage, all members of that family have access, excluding people with health insurance
from someone outside of the family.

3 The take-up rate is defined at the person level, since it is possible for some family members to
be covered by an employer, while others are uninsured or have other coverage.

Low-Income Latinos and Whites Lose

hile employer coverage for low-income blacks remained fairly
constant between 2001 and 2003, low-income Latinos and whitesdefined as
income below 200 percent of the federal poverty level, or $36,800 for a family
of four in 2003saw dramatic declines in employer-sponsored insurance (see
Table 3). Employer coverage for low-income Latinos dropped
from 28.3 percent in 2001 to 22.9 percent in 2003, while low-income whites with
employer coverage dropped from 46.3 percent to 41.8 percent during the same
period.

The proportion of low-income Latinos with access to employer coverage dropped
10 percentage points between 2001 and 2003, from 58 percent to 48 percent. The
take-up rate among low-income Latinos with access to employer coverage also
declined significantly from 64.5 percent in 2001 to 53.6 percent in 2003 (see
Table 4).

Low-income white Americans also saw a significant decline
in access to employer coverage, with the proportion eligible for
employer coverage dropping from 72.6 percent in 2001 to 64.8
percent in 2003. Unlike Latinos, however, low-income whites
take-up rates remained fairly constant with almost 77 percent
taking up employer coverage in 2003.

2 Other coverage includes private nongroup insurance, private insurance
obtained from someone outside the family, Indian Health Service and other
miscellaneous coverage. Military insurance and Medicare for disabled persons
are excluded from this analysis.

* Change from previous survey is statistically significant at p <.05.

# Change from 1997 to 2003 is statistically significant at p <.05.

Notes: Bold text shows statistically significant differences from whites.
Low income is defined as having a family income less than 200 percent of
the federal poverty level.

1 A working family is defined as one in which total number
of hours worked by all adult members of the family is 20 or more hours per
week. Dependents of adults on active military duty are included while families
in which all adult members are self-employed and have no paid employees
are excluded.

2 Access rate is defined at the family level. As long as one member of the
family has access to employer coverage, all members of that family have
access, excluding people with health insurance from someone outside of the
family.

3 The take-up rate is defined at the person level, since it is possible
for some family members to be covered by an employer, while others are uninsured
or have other coverage.

* Change from previous survey is statistically significant at p
# Change from 1997 to 2003 is statistically significant at p
Notes: Bold text shows statistically significant differences from whites.
Low income is defined as having family income less than 200 percent of the
federal poverty level.

Source: Community Tracking Study Household Survey

Public Coverage Increases

ublic insuranceprimarily Medicaid and the State Childrens
Health Insurance Program (SCHIP)filled insurance coverage
gaps for many nonelderly Americans, especially Latinos. In
2003, slightly less than one in four Latinos (22.5%) had public
insurance, compared with one in six (15.6%) in 2001.1 The
proportion of nonelderly whites with public coverage increased
from 5.9 percent in 2001 to 8.1 percent in 2003, while the rate of
blacks with public coverage in 2003 was 22.6 percentstatistically
unchanged from 2001.

The increase in public coverage among Latino children was especially striking
(see Supplementary Table 1). In 2001, nearly one in three
(29.7%) Latino children was covered by public insurance, compared with more
than two in five (43.6 %) in 2003. Between 2001 and 2003, both Latino adults
and children saw increases in public insurance and declines in employersponsored
insurance, and the pattern was similar, yet not as sharp among non-Latino whites.

Among low-income people, shifts toward public coverage
were even more pronounced among nonelderly Latinos and
whites. Low-income Latinos with public coverage increased
from 24.8 percent in 2001 to 33.4 percent in 2003, while, at
the same time, public coverage rates for low-income whites
increased from 20.5 percent to 27.1 percent.

Access Gaps Remain

hifting forms of insurance coverage—from employer coverage
to public insurance—had little effect on access to medical
care among nonelderly blacks, Latinos and whites. In assessing
minority health care disparities, four measures of access among
whites, blacks and Latinos were examined:

whether people have a regular health care provider;

whether people saw a doctor in the last year;

use of emergency rooms for care; and

whether people had access to specialists.

With the sole exception of decreased access to specialists
among blacks, access to care did not change from 2001 to 2003.
Moreover, gaps in access between Latinos, blacks and whites
persisted. In tracking access to medical care between 1997 and
2003, nonelderly blacks and Latinos consistently reported lower
levels of access to care than whites.

Reduced access to care can result in delayed diagnosis and
treatment and contribute to well-documented disparities in
minority health.2 Many of the chronic diseases that contribute
to racial and ethnic health disparities require early detection
and monitoring. Having a regular health care provider who
knows patients individual history and health care needs, along
with periodic contact with a physician, can help build trust and
rapport between caregivers and patients. Seeing physicians in
hospital emergency departments for nonurgent care contributes
to problems with continuity and coordination of care. Finally,
disparities in access to specialist care can create additional problems
for patients with complex conditions.

Access to Care

onelderly whites continue to be more likely to have a regular
health care provider than either blacks or Latinos. Between 1997 and 2003, less
than two-thirds of blacks and somewhat more than half of Latinos reported having
a regular provider, compared with three-quarters of whites (see Table
5). Latinos and blacks also are less likely than whites to have seen a doctor
in the past 12 months. With the exception of a slight increase in 1999, less
than three in four nonelderly blacks and slightly more than three in five Latinos
saw a doctor, compared with four in five whites.

Blacks use of emergency rooms to obtain care continued to decline, from 10.4 percent of all doctor visits in 1997 to 9.1 percent
in 2003. However, blacks continue to use emergency rooms
in greater proportions than whites. In 1997 and 1999, Latinos
tended to use emergency rooms for doctor visits in similar proportions
as whites. However, between 2001 and 2003, Latinos
made significantly more of their health care provider visits in
emergency rooms than whites.

Nonelderly whites access to specialists remained virtually
unchanged between 1997 and 2003, with about 27 percent of
whites most recent doctor visits occurring with specialists.
Blacks and Latinos were much less likely to have the same level
of access to specialists as whites. In fact, blacks access to specialists
declined significantly. Between 2001 and 2003, the percentage
of blacks whose last doctor visit was to a specialist dropped
from 24.4 percent to 19.8 percent.

Gaps in access to care also persisted among insured and uninsured blacks,
Latinos and whites (see Supplementary Tables 2 and 3). For
example, 80.1 percent of insured blacks in 2003 reported seeing a doctor in
the past year, compared with 48 percent of uninsured blacks. Similarly, 74.8
percent of insured Latinos and 82.6 percent of insured whites in 2003 saw a
doctor, compared with 38.5 percent of uninsured Latinos and 50.3 percent of
uninsured whites.

In 2003, about 23 percent of both Latinos and blacks relied
on public coveragea far different situation than in 1997, when
13.7 percent of Latinos and 19.3 percent of blacks had public
coverage. Increased reliance on public coverage can be viewed
either as an encouraging developmenta result of expanded eligibility
and increased outreachor a worrisome oneminorities
disproportionately losing employment coverage as a result
of job market changes. Either way, as states wrestle with tight
budgets, Medicaid and other state coverage programs are particularly
vulnerable to budget cuts, leaving Latinos and blacks at
risk for losing coverage.

Additionally, blacks and Latinos are more likely than whites
to be disconnected from the health care system. For example,
they are less likely than whites to have a regular caregiver, less
likely to have seen a physician and more likely to see physicians
in emergency rooms. When they visit physicians, blacks and
Latinos are less likely than whites to see a specialist. The decline
in access to specialist care among blacks is particularly troubling.

The access gap has changed little since 1997 and in some
cases has increased. As long as access problems for racial and
ethnic minorities persist, it is unlikely that health disparities will
diminish significantly.

Notes

1.

Public coverage includes Medicaid, SCHIP and other state coverage.
Private coverage includes nongroup insurance and private insurance
obtained through someone outside the family. Persons with military
coverage and people enrolled in Medicare because of disability were
excluded from this analysis.

Data Source

This Tracking Report presents findings from the This Tracking Report presents
findings from the HSC Community Tracking Study (CTS) Household Survey, a nationally
representative telephone survey of the civilian, noninstitutionalized population
conducted in 1996-97, 1998-99, 2000-01 and 2003. For discussion and presentation,
we refer to a single calendar year for the first three surveys (1997, 1999 and
2001). Data were supplemented by in-person interviews of households without
telephones to ensure proper representation. The first three rounds of the survey
contain information on about 60,000 people, while the 2003 survey contains responses
from about 47,000 people. Response rates ranged from 60 percent to 65 percent
for the first three rounds and were 57 percent in 2003. The estimates in this
report are representative of people under age 65 in three The estimates in this
report are representative of people under age 65 in three racial or ethnic groups.
Black refers to all non-Latino blacks, and white refers to all non-Latino whites.
Insurance status reflects coverage on the day of the interview.